I'm a 29 years old fit man, and I've been on HIV drugs for 2,5 years now. I'm a year into my second regimen (Combivir and Stocrin)as I had to change from my first regimen (Videx,Zerit and Ziagen) due to lactic acedosis. My viral load has been below 20 copies for a long time, but the test taken on 7 August 2002 showed a viral load of 784 copies and a drop in CD from 470 in April to 400 now. I also had swollen glands under my arms for a couple of days last week. I remember having been delayed 4-5 hours in taking my meds some time (not that often though), and I can't remember having missed any dosed (but cannot rule it out either, as I sometime rush out of the door in the morning). I'm quite nervous about these new viral counts, so I hope that you will take the time to answer these questions:
1) Am I becoming resistant?
2) If yes, could such resistance possibly be reversed, if I take my meds religiously as from today (i.e. strict 12 hour intervals)
3) My doctor told me to come back in 4 weeks for new blood tests? It seems a long time to wait - would you recommend the same?
4) What's worst case? That I have to go on a whole new group of meds, i.e. protease inhibitors? I would really hate that because of the side effects (I have none on my current regimen).....
Thank you for your time!!!

Response from Dr. Little

Well, after a prolonged period of viral loads below 20 copies, I would in fact be worried about a viral load of 784. Obviously this could be a lab error, but with the CD4 cell count drop as well, I think it is worth taking seriously. I would immediately repeat the viral load and order a resistance test. The question of whether to remain on treatment while waiting for resistance test results is still an unclear - in general, if I am very concerned (as I would be in your case), I make my best guess change in treatment while waiting for the test results. The alternative would be to stop treatment while waiting for test results. The resitance test is particularly useful in situations like yours since it is impossible to guess whether you have resistance to 3TC or efavirenz (Stocrin) - both seem possible. This information would be useful in helping to guide the choices of treatments in your next regimen - or alternatively, slight modification of your current regimen. While poor adherence is a major factor in the development of drug resistance in many people, it is also possible that the potency of this regimen is simply not sufficient (especially if you have any resistance mutations present from your first treatment regimen).

As for improving your immediate adherence, while this is always a good idea, if you are developing resistance, simply taking the drugs as prescribed is not likely to make the difference you wish (i.e. reverse the process).

It is always hard for me to judge the urgency of these situations from a long distance without all the facts, but I would say that in general, I would have repeated the viral load and sent the genotype immediately and then also addressed what to do with your current treatment while waiting for the resistance test results.

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